1. Field of the Invention
The present invention relates generally to a novel and improved problem solving process (PSP), and particularly, a problem solving process in relation to the medical field/domain
2. Description of the Related Art
Before disclosing the details of the problem solving process in relation to the medical field/domain, the applicant will synopsize the current state of computerized design in this area following 36 years of continued efforts. Medicine is a highly complex field/domain that takes years of training to become proficient in. It has the challenges of following data over decades, resolving acute and chronic conditions, documentation requirements with medical legal implications, and true life and death situations. It is also a field where adoption of computerized medical record systems has had extremely limited success despite decades of investment, research, and strong external pressures to computerize. Applicant contents that the entire field of medicine can be reduced to a PSP or Problem Solving Process Computing (PSP Computing). PSP Computing distills the entire field of medicine to the “Problem Solving Process,” with all its necessary outputs or charting (documentation, prescriptions, orders, instructions, alerts, scheduling tasks, etc.) automatically produced as a by product of solving the problems.
Applicant contends that the same Problem Solving Process can do the same in any field/domain that solves problems over time. This application will primarily show this concept related to medicine, but will show screenshots of other fields/domains that could be converted using the same principles. Specifically, Applicant further claims that the exact same Process can be applied to any field/domain (i.e. law, consultancy, computer programming, detective work, etc.) that solve problems over time.
Before proceeding, the Applicant will discuss the difference between work of practicing ones profession (problem solving) and the work of documenting what occurred. Let us take as an example, a medical doctor (M.D.), physical therapist, or chiropractor performing a therapeutic maneuver or dispensing a prescription to relieve a patient's back pain. Solving the problem is the “real-” work or goal of the encounter. The client wants the professional/doctor to solve the problem. Solving the problem is what the professional has been trained to do. To most professionals, problem solving work can be exhilarating, as they are using their skills to accomplish a goal that makes them matter. If solving the problem provides a complete cure of the problem, never to recur, the quality of the documentation in that simple example would potentially be immaterial. Yet, in the medical field/domain, and majority of others, it is the documentation, or the “work-” work that becomes the major requirement of the visit for payment and medical legal reasons.
Since this documentation/paperwork has both financial and legal ramifications, software solutions have focused on duplicating the documentation requirements of medicine and other fields/domains, as they convert from the “paper world.” Designed around the outputs of the fields/domains they computerize, they are fundamentally flawed. This form/output based design leads to greater documentation requirements, like proper formatting requirements. These requirements lead to steep learning curves and often more time documenting the encounter than time spent solving the problem. Computerized documentation requirements are often more cumbersome and time consuming than its “paper world” counterpart. This form/output based design increases the workload of the professional, and even with the many generic advantages of computers (like data analysis or location independence), will never lead to the efficiencies of a Problem Solving Process design.
Before disclosing the details of the Problem Solving Process in relation to the medical field/domain, Applicant will synopsize the current state of computerized design in this area following 36 years of continued efforts. For example, in the medical domain, designing around the charting process in Electronic Health Records (EHRs) or Electronic Medical Records (EMRs) has been the standard design since 1969. This approach has not had significant market penetration (currently reported at 5 to 13 percent of M.D.'s use EMRs despite billions of dollars in investments and extraordinary public, administrative, and payor pressure to computerize).
The “Paper World”
The original thrust to computerize the medical record came from Larry Weed's seminal work in 1969. See L. L. Weed, Medical Records That Guide and Teach, N. Eng. J. Med., 593-600 278:11 (1968). He correctly concluded that the medical record had no standard format. It was entirely at the whim of the individual practitioner regarding how much detail of the patient's complaints was put in the note. Prior to Weed, many practitioners had the complete history and physical records of their entire patient population on 5″×6″ index cards. These index card medical records had an extremely filtered set of details about the patients' medical history. For prescriptions, the notes would often just have the date and the drug, such as “4/01/1960—Penicillin I.M.,” with no indication of why the medication was given and what was the outcome of the intervention. Even in hospitalized patient records, the details of many problems were often meshed together in a single paragraph in a sloppy manner. If a problem such as chest pain led to an electrocardiogram (EKG) and a cardiology consultation, these “plans” were often not even linked to their source. Instead, they were simply listed at the end of the note, or they were not listed in the note at all and just ordered on an order sheet in a separate part of the chart. The outcome of these plans was generally not individually noted in the follow up. This entire record keeping process was very informal. It was not formalized as it was not a necessity or an advantage in the “paper world” to chart it.
Computerization of the Medical Note
Dr. Weed proposed a new format for the medical note around two fundamental concepts. These were the Problem Oriented Medical Record (P.O.M.R.) and the Subjective, Objective, Assessment, and Plan (S.O.A.P.) chart note. The P.O.M.R. elevated each of the patient's problems to the highest level in the chart and then organized the S.O.A.P. format as the means of reporting how the problem was doing in the follow-up visits. He also championed the use of flow sheets to follow the data that accumulated around the problems for simpler analysis.
The result of Weed's efforts led to “Problem Lists” as an organizational tool and the S.O.A.P. note as the formatted note structure underneath each problem. However, the patient could still be cared for without formally using any component of the Weed method. The M.D. might not be as organized or the documentation might seem less complete, but the patient could be cured nonetheless. The amount and form of documentation was still entirely up to the individual, despite Weed's New England Journal of Medicine article and the adoption of the P.O.M.R./S.O.A.P. method at some medical schools. Many M.D.s continued to write notes in their own format, and others used the P.O.M.R./S.O.A.P. style intermittently, and many were exclusively P.O.M.R./S.O.A.P. Even at the peak of its popularity, the P.O.M.R./S.O.A.P. format never reached even a 50 percent level of adoption in the medical record. See Letter of K. C. Meyers & H. J. Miller to Academy of Medicine, The Importance of Cleaning up S.O.A.P., 72:9 933-4 (1997). See also Letter of A. S. Rubin to Academy of Medicine, Another Way to Enhance S.O.A.P.'s Usefulness, 73:445 (1998).
Despite this, when EMRs began to be developed post 1969, this was the only documentation standard in the medical field/domain that was available. A “standard” with less than a 50 percent adoption rate is fated to have issues, and such it has been for the Weed design. As time went on, the adoption of P.O.M.R./S.O.A.P. EMRs was underdeveloped. Adjustments were made with some EMRs still having a Problem List, but abandoned the requirement of using it for charting. Follow-up notes became an unstructured blank sheet of paper. Other EMRs completely abandoned a problem focus, but enhanced the blank sheet of paper with shortcut key strokes or templates. These EMRs are often described as “Encounter Based” mimicking the paper world format of not requiring an association between the plans of treatment with the problems they were ordered for. In spite of it's free form, the Encounter Based approach was more cumbersome than the paper record, as most physicians were not good typists and it interfered with the face to face contact that could be made with the Patient chart.
A comprehensive review of the designs of EMRs in the last 36 years can be classified into 3 views: (1) source-oriented (organizing the record into sections based on source of data, such as, x-ray, labs, notes), (2) time-oriented (organizing data chronologically), and (3) concept-oriented (the most famous example being the Weed P.O.M.R. or S.O.A.P. construct). An additional view is called the “Knowledge-based, Cconcept-oriented” view. This view was an attempt to decrease the information overload of current EMRs. It attempted to filter results based on predefined views, such as “show all pulmonary tests for CHF.” The present invention is a new approach to EMRs/EHRs called “Problem Solving Process Computing.” It is not a view, or a format, it is a process with major advantages over all of these concepts.
The Trouble with S.O.A.P.
The Weed design had a serious design defect, that was especially evident as one tried to computerize the paper record. This fundamental flaw was focusing first on “S” or “subjective” and looking at the “O” or “objective” second. Thus, the process is designed around the concept that the first thing you chart on a follow up visit is the “S”—how the patient feels about the state of the problem and any new related verbal information regarding the condition. Then, “S” is followed by the “O” which represents objective or measurable elements. This was defined by Weed as “Test Results and Physical Findings.” The “A” is for the doctor's “assessment,” and the “P” is for the “plans.”
Working off of this standard was a major obstacle to designing an effective EMR. That is because it the S.O.A.P. method puts the “S” in front of the “O.” This did not match the actual behavior of the physicians, making it an artificial construct. There was a disconnect between what was documented and the actual order of what was done. Worse, the subjective section is substantially changed by the “P” plan results. That is, the specific questions that are asked in the verbal exchange (subjective) part of the visit, is substantially altered by the plan results. This combination of asynchrony and the effect the plan results have on the subsequent questions, are the fatal flaw of the S.O.A.P. note when it comes to computerization.
In contrast to the S.O.A.P. methodology, practitioners first looked at the “objective” section that represented plan results, prior to asking any (subjective) questions. This objective analysis was routinely done by the practitioner before walking into a patients' room in a hospital or office. See K. C. Meyers et al., The Follow up note: Format and Requirements, Specifications for the Computerized Medical Record, AMIA Proceedings: Orlando, Fla. (1997). Even doctor-to-patient phone calls would be preceded by a brief chart review before telephoning the patient. This is because plan results always effect what questions that are asked in the “S” of the S.O.A.P. note. For example, if a patient complained of a headache and an MRI of the brain did not show a brain tumor, then the clinician would accept that the patient did not have a brain tumor based on the MRI. The clinician would not ask questions related to the possibility of brain tumor in the “S” section. Another example is a patient with a problem of abdominal pain. If the patient had a Computer Tomography Scan (CT scan, or CAT Scan) that showed Diverticulitis, the M.D. would emphasize questions in the “S” section related to peanuts, seeds, popcorn and other related items that could cause a flare of this illness.
The Institute of Medicine
The Institute of Medicine's (IOM) 1991 seminal work entitled The Computer-Based Patient Record: An Essential Technology for Health Care declared the need to computerize the medical record for healthcare. See R. S. Dick, E. B. Steen, The Computer-Based Patient Record: An Essential Technology for Health Care, Institute of Medicine Committee on Improving the Patient Record (1991). The goal was to computerize the medical record within 10 years. The IOM spun off the Computerized Patient Record Institute (CPRI) and the Nicholas Davies Award to pursue this goal. The CPRI promoted standards and adoption of EMRs, including a standard that listed 154 requirements of a satisfactory EMR. Eventually, the CPRI produced a document stating that if the specific 154 requirements of an EMR were accomplished, it would be successful. In 1999, after over 100 million dollars invested by HBOC, the Smart Medical Record was pulled from the market, having completed 140 of the CPRI 154 requirements, partially done with 10 others, and only had 4 requirements not addressed. This certainly brings up the issue of perceived requirements versus the “real” requirements. It is the Applicant's contention that all written requirements for EMRs, such as those proposed by the Institute of Medicine focus on the chart structure, and not the real work of the medical encounter.
Managed Care
During the 1990s, EMRs were heavily promoted by managed care companies which were transforming healthcare in their own right. This led to massive investment of venture capital into EMRs due to manage care's desire to measure the care delivered. This also led to additional “reasons” why the EMR was essential. Data measurement was needed if one was to apply more strict business principles to medicine. Goals included the elimination of the cost of paper records, legibility, HEDIS (Health Plan Employer Data and Information Set) scores (essentially healthcare report cards on the providers). Even these compelling business mandates did not prove compelling enough to overcome the basic usability problems of the chart-based EMR. Some of these same arguments are being proclaimed today by the Government and the Institute of Medicine as the reason EMRs should be adopted now.
The Internet
With the Internet emerging, some of these companies leveraged their stock valuations to temporarily reap billions of dollars of paper wealth on the prediction that the portability of the Internet was the essential technological development that would make EMRs successful. The Internet did not lead to adoption and these companies had a reversal of fortune. Application Service Providers (ASPs) were also promoted as the solution. The theory was that the cost of the application would be less if managed centrally over a DSL or T1 line, and that would convince M.D.s to change; it was not the solution. The market for EMRs temporarily crashed with the extraordinary amount of money lost in these ventures and the bursting of the internet bubble.
Electronic Health Record (EHR)
In 2000, the IOM released its next EMR report. See Linda T. Kohn et al., To Err is Human—Building a Safer Health System, Committee on Quality of Health Care in America, Institute of Medicine (2000). Specifically, this report claimed that nearly 100,000 deaths per year could be prevented by computerized information systems. They contended that these errors could be reduced by using information technology. The report was followed by an attempt to improve the marketability of the EMR by changing the name to EHR, or Electronic Health Record. Just as EMR had replaced the Computerized Patient Record (CPR) in the mid 1990s, it was hoped a change in name and slight change in focus would improve the marketability of these products.
The Government
The government became more directly involved due to 9/11 and the need for an EHR to be in place in the event of a terrorist attack utilizing biological agents. In addition to these national security issues, in the face of rising Medicare costs, the Government has become increasingly energized to seek healthcare savings from the touted efficiencies that EMRs could bring.
Employers
Managed care was the beginning of trying to lessen healthcare premiums to employers by measuring the quality and necessity of tests and procedures. The increasing pressure of globalization on businesses has put them squarely behind any initiatives that would increase the measurability of the services they are buying.
All of the above were compelling reasons as to why EMRs would be valuable to society. They addressed the societal advantage of computerization without thoughtfully addressing the usability issues facing the physician. Like the first car builders who thought the car should be steered with horse reins, the EMR was designed around the chart.
As noted before, the focus of all EMR designs has been on the chart and charting. There was no standard across physicians, even within the same specialties. The most common design for note writing was S.O.A.P. which was at best used by 50 percent of M.D.s, and therefore programs formatted on the S.O.A.P. Weed method required greater than 50 percent of M.D.s to change their habits. Many EMRs adopted problem-specific templates which were useful for first time visits but failed in follow-up notes. This failure was critical since the vast majority of visits are follow-up visits. Others adopted a blank text field and used short hand techniques to auto-generate text. As with the template-driven notes, the S.O.A.P. and free text with “short hand” failed miserably in the follow-up visits.
In addition, the structure of these conventions led to boiler plate, often bulky notes that either regularly repeated past text to the point that they were often inaccurate. To save time, some physicians just typed in terse free text notes that often do not provide sufficient detail to truly describe what the M.D. had just done. While the computer provides greater legibility, the narrative is often lost in the sameness or incompleteness of the note, i.e. a long note that says almost nothing new (for the third time in a row) or a short note that is bereft of detail.
Aside from poor market adoption, there has been provocative literature that questions designing EMRs around the chart structure. For instance, Edwin Tufte, an authority on the representation of data sets in logical patterns, has strongly spoken out against the design of the chart as a basis for an EMR. His quote, “the chart is a data dump, it was not designed with the care of the patient in mind” identifies the problem of designing an EMR around the chart. His solution of a graphical representation with differential weighting of data based on the time elements is not the correct solution, but it does identify the problem with standard chart based design head on.
In addition, The Journal of the American Medical Association (JAMA) published an editorial in March 2005 highly critical of the current chart based designs. See R. L. Wears & Marc Berg, Computer Technology and Clinical Work Still Waiting for Godot, J. Amer. Med. Ass'n, 293:1261-3 (2005). This article recognizes the problem that current designs create on physician workflow, and questioned claims that computerization of the note was having a net positive effect on patient errors. It appeared that the problems it solved were replaced with problems it created. Users were clearly hindered by the requirements of the system and its focus on the format/structure the program funneled them into, rather than funneling knowledge and workflow enhancements to the user.
This design can have serious, negative effects at the hospital bedside. This was illustrated in two publications in 2005. An article in Pediatrics from December 2005 questioned the safety improvements that computers are supposed to provide. In this article, an EMR was shown to actually increase the death rate in a pediatric intensive care unit (ICU). See Han et al., Unexpected Increased Mortality after Implementation of a Commercially Sold Computer Order Entry System, Pediatrics; 1506-12, Vol. 116 No. 6 (December 2005). As noted in the article, computerization has increased the time it takes to document the visit. This documentation time decreases doctor-patient time. In an ICU setting, where each minute counts, this can be the difference between life and death.
A second article addresses this time problem directly. A review from September 2005 analyzed the time physicians spent documenting notes and writing orders in all published reports on EMRs for the last 20 years. See L. Poissant, et al., The Impact of Electronic Health Information Systems on Time Efficiency of Physicians and Nurses: A Systematic Review, J. Am. Med Informatics Assoc., 505-16 Vol. 12 No. 5 (September/October 2005). This extensive review documented a range of increased work for physicians, from 98 to 328 percent per working shift. The average increase in time spent documenting the encounter and ordering necessary tests was 238 percent. This increase in documentation time logically effects doctor-patient time and helps explain the findings in the Pediatric article. It speaks volumes as to why there has been poor adoption of EMRs/EHRs.
Despite decades of efforts, billions of dollars of investments, government mandates, etc., the benefits that EMRs could provide patients and physicians have been minimized due to a serious design flaw. The flaw is that they are documentation- or chart-based.
In discovering and resolving this design flaw, the Applicant will advance the entire medical field/domain. Properly implementing Problem Solving Process Computing will have similar ramifications to all knowledge fields/domains.